Study population
The link to the survey was distributed amongst the medical students (773 in total), obtaining 143 responses (response rate of 18.5%). The characteristics of the respondents are presented in Table 1. Mean age was 22.1 (SD: 2.68) years. About two thirds (70.6%) were in fourth, fifth or sixth year of their medical studies. 98 out of the 143 (68.5%) respondents were female.
Table 1
Variable | Category | All respondents (143) | Respondents with profile (121) | Respondents without profile (22) |
N(%) | N(%) | N(%) |
Gender | Male | 45(31.47) | 39(32.23) | 6(27.27) |
Female | 98(68.53) | 82(67.77) | 16(72.73) |
Year of studies | First to third year students | 42(29.37) | 37(30.58) | 5(22.73) |
Fourth to fifth-year students | 48(33.57) | 38(31.40) | 10(45.45) |
Sixth-year students | 53(37.06) | 46(38.02) | 7(31.82) |
Starting year | 2013 | 8(5.59) | 6(4.96) | 2(9.09) |
2014 | 50(34.97) | 44(36.36) | 6(27.27) |
2015 | 26(18.18) | 22(18.18) | 4(18.18) |
2016 | 15(10.49) | 11(9.09) | 4(18.18) |
2017 | 19(13.29) | 17(14.05) | 2(9.09) |
2018 | 15(10.49) | 11(9.09) | 4(18.18) |
2019 | 10(6.99) | 10(8.26) | 0(0.00) |
Autonomous community | Cantabria | 78(54.55) | 64(52.89) | 14(63.64) |
Asturias | 20(13.99) | 18(14.88) | 2(9.09) |
Castile and Leon | 13(9.09) | 10(8.26) | 3(13.64) |
Andalusia | 7(4.90) | 7(5.79) | 0(0.00) |
Madrid | 7(4.90) | 6(4.96) | 1(4.55) |
Basque Country | 4(2.80) | 4(3.31) | 0(0.00) |
Castile La Mancha | 4(2.80) | 4(3.31) | 0(0.00) |
Others | 10(6.99) | 8(6.61) | 2(9.09) |
Age,(mean(sd)) | 22.13(2.68) | 21.97(2.37) | 23.05(3.96) |
Selected profiles
We selected the three profiles explaining more variance (56%); all three profiles were interpretable, so from here on we will refer them as profiles 1, 2 and 3. 121 respondents (84.6%) could be included in one of these profiles and 22 (15.4%) could not be classified and were excluded from the statistical analysis.
Profiles are characterized by their distinguishing statements; from here on, each statement will be presented followed by its number, its position on the Q-grid (from − 3 to + 3), and an * in case of being a distinguishing factor. For instance, when describing profile 1, we use (#5, 0*), which indicates statement #5 in Table 2 (“I would place more value on end-of-life treatments than many medical treatments for non-terminal conditions”) scored 0 in people with profile 1 and allows to distinguish this profile from profiles 2 and 3.
Table 2
Factor scores per statements
Statement | F1 | F2 | F3 |
1. Patients should have the right to refuse life-extending treatments if they choose. | 3 | 3 | 3* |
2. At the end of their life, patients should be cared for at home with a better quality of life rather than have aggressive and expensive treatments that will only extend life for a short period of time. | 1 | 0* | 1 |
3. If somebody wants to keep fighting until the last possible moment, they should be allowed to do so, regardless of cost. | 2 | 2 | -1* |
4. It is important to give a dying person and their family time to prepare for their death, put their affairs in order, make peace and say goodbyes | 2 | 2 | 2 |
5. I would place more value on end-of-life treatments than many medical treatments for non-terminal conditions. | 0* | -1 | -2* |
6. Expensive drugs for people who are terminally ill and won't benefit very much are not a good use of public funding. | -2 | -1 | 0* |
7. It is human nature to want to preserve life and go on living for as long as we can - it is one of our most basic instincts. | -1* | 2* | 1 |
8. If a life-extending treatment for terminally ill patients is expensive, but the only treatment available, it should still be provided | 1 | 1 | 0* |
9. It may not sound like much, but a few extra weeks or months might mean an awful lot to a family affected by a terminal illness | 2 | 3* | 2 |
10. Life should only be extended if the patient's quality of life during that time will be good. | 1 | 0* | 2 |
11. Real help and compassion should be about providing a death with dignity instead of more drugs to get a few more weeks or months out of a very sick body. | 2 | 0* | 2 |
12. A year of life is of equal value for everyone. | -2 | -1 | -3* |
13. We should spend proportionately more on patients when we feel those patients have not had their fair innings - in terms of the length of their life or the quality of that life. | 1 | 1 | 0* |
14. To extend life in a way that is beneficial to the patient is morally the right thing to do. | -1 | 0* | -2 |
15. If the means of helping someone live longer exists, it is morally wrong to deny them the treatment. | 0 | 2* | -1 |
16. Not giving access to life-extending medicine to a person with a terminal illness is the same as killing them. | -1 | 0* | -2* |
17. Treatments that are very costly in relation to their health benefits should be withheld. | -2 | -2 | -1 |
18. End-of-life drugs are not a cure, they are life-prolonging. There is no point in delaying the inevitable for a short time. | -1 | -2* | -1 |
19. Patients at the end of life will grasp any slightest hope but that is not a good reason for the NHS to provide costly treatments that may extend life by a short time. | -1 | -2* | 1* |
20. Treatments that provide a short life extension are not worth it - they are only prolonging the pain for the patient's family/friends. | 0 | -3* | -1 |
21. Extending life for people with terminal illnesses is only postponing death. | 0* | -3* | -2 |
22. Life is sacred and if it is possible to preserve life, every effort should be made to do so. | -3 | 0* | -3 |
23. I wouldn't want my life to be extended just for the sake of it - just keeping breathing is not life. | 3 | 1 | 3 |
24. Everyone has a right to basic healthcare but there has to be limits and expensive, end-of-life, drugs are not basic care. | -3* | -1 | 0* |
25. It's important to provide life-extending treatments to give a dying person time to reach a significant milestone, like a family event or a personal achievement. | 0 | 1* | 1 |
26. I think life-extending treatments for people who are terminally ill are of less value as people get older. | -2 | -2 | 0* |
27. Treating people at the end of life is not going to result in big health gains but the health system should be about looking after those patients in greatest need. | 0 | 1 | 0* |
28. An objective measure of health expenditure control could be to legalize the euthanasia process. | 1 | -1* | 1 |
Statement #4: “It is important to give a dying person and their family time to prepare for their death, put their affairs in order, make peace and say goodbyes” was identified as a consensus statement. The three profiles agreed in this statement with + 2.
Profile 1: Students prioritizing patient’s wishes and quality of life
The first of the three profiles accounts for 17.5% of the sample (25 respondents). Figure 2 shows the composite Q-sort for this group.
People holding this view do not express preference in statements that are closely related to wishes or perceptions of the terminal patients or their relatives: “Extending life for people with terminal illnesses is only postponing death” (#21, 0*) or “I would place more value on end-of-life treatments than many medical treatments for non-terminal conditions” (#5, 0*). They also worry about the patient’s wishes, respecting their power to decide about their own life: “If somebody wants to keep fighting until the last possible moment, they should be allowed to do so, regardless of cost” (#3, 2).
They do not defend life at any cost: they score negative in “Life is sacred and if it is possible to preserve life, every effort should be made to do so” (#22, -3) and “It is human nature to want to preserve life and extend it as long as we can – it is one of our most basic instincts” (#7, -1*). They do not encourage a terminal patient to prolong his life unless ensuring good quality of life: “Real help and compassion should be about providing a death with dignity instead of more drugs to get a few more weeks or months out of a very sick body” (#11, 2).
This view ignores the burden of health care expenses, justifying the most effective treatment regardless of the cost. Therefore, they score those sentences related with prioritizing costs over health care as negative: “Everyone has a right to basic healthcare but there have to be limits and expensive end-of-life drugs are not basic care” (#24, -3*); “Expensive drugs for people who are terminally ill and won’t benefit very much are not a good use of public funding” (#6, -2); “Treatments that are very costly in relation to their health benefits should be withheld” (#17, -2). Finally, respondents of this profile show a special sensitivity towards terminal patients, so they mark the statement “I think life-extending treatments for people who are terminally ill are of less value as people get older” as negative (#26, -2).
Profile 2: Students believing that life must be extended whatever the cost
Forty-two respondents (29.4%) fit in the second profile. Figure 3 shows its composite Q-sort. People with this view advocate life extension in any case; therefore, they agree with “It is human nature to want to preserve life and go on living for as long as we can – it is one of our most basic instincts” (#7, 2*) and “If the means of helping someone live longer exists, it is morally wrong to deny them the treatment” (#15, 2*), while disagreeing with “Extending life for people with terminal illnesses is only postponing death” (#21, -3*).
They defend life at any cost: “If somebody wants to keep fighting until the last possible moment, they should be allowed to do so, regardless of cost” (#3, 2). In contrast to the other views, they reject euthanasia since it is presented as a measure of health expenditure control, and this is not a primary concern for them: “An objective measure of health expenditure control could be to legalize the euthanasia process” (#28, -1*).
Consequently, respondents included in this profile maintain that every effort should be made to prolong life, even if it is for a short time: “It may not sound like much, but a few extra weeks or months might mean an awful lot to a family affected by a terminal illness” (#9, 3*); “It is important to provide life-extending treatments to give a dying person time to reach a significant milestone, like a family event or a personal achievement” (#25, 1*); and, thus, they despise statements undervaluing life vs. costs: “Treatments that provide short life extension are not worth it – they are only prolonging the pain for the patient’s family/friends” (#20, -3*); “End-of-life drugs are not a cure, they are life-prolonging. There is no point in delaying the inevitable for a short time” (#18, -2*); “Patients at the end of life will grasp any slightest hope but that is not a good reason for the NHS to provide costly treatments that may extend life by a short time” (#19, -2*).
Similar to profile 1, they consider terminal patients worth special attention, though they accept that important health gains are not expected despite greater spending; therefore, they disagree with: “Treatments that are very costly in relation to their health benefits should be withheld” (#17, -2); “I think life-extending treatments for people who are terminally ill are of less value as people get older” (#26, -2).
The fact that students with this profile do not reject sentences such as “Not giving access to life-extending medicine to a person with a terminal illness is the same as killing them” (#16, 0*); “Life is sacred and if it is possible to preserve life, every effort should be made to do so” (#22, 0*) is another indicator of how much they respect life. These two sentences distinguish this profile as students in profiles 1 and 3 score them negatively.
Respondents included in this profile do not show a clear position in those statements evaluating expected quality of life of a terminal patient. They do not agree with sentences like “At the end of their life, patients should be cared for at home, with a better quality of life, rather than have aggressive and expensive treatments that will only extend life for a short period of time” (#2, 0*); “Life should only be extended if the patient's quality of life during that time will be good” (#10, 0*); “Real help and compassion should be about providing a death with dignity instead of more drugs to get a few more weeks or months out of a very sick body” (#11, 0*), suggesting that they prioritize life extension over quality of life. These three sentences distinguish profile 2 as students in profiles 1 and 3 score them positively.
Finally, this profile does not show a clear position when the moral problem of prolonging the life of a terminally ill patient is assessed ("To extend life in a way that is beneficial to the patient is morally the right thing to do") (#14, 0*). In contrast, respondents in the other two profiles strongly disagree with this statement.
Profile 3: Students maximizing health benefits and economic aspects
The third profile includes most respondents, accounting for 37.8% of the sample (54 participants). Figure 4 shows the composite Q-sort for this profile.
The main difference with the other two profiles is that they consider that the Public Health System should prioritize the cost of medical care: “Patients at the end of life will grasp any slightest hope but that is not a good reason for the NHS to provide costly treatments that may extend life by a short time” (#19, 1*). Therefore, they negatively score sentences such as “I would place more value on end-of-life treatments than on many medical treatments for non-terminal conditions” (#5, -2*) and “If somebody wants to keep fighting until the last possible moment, they should be allowed to do so, regardless of cost” (#3, -1*). They would support patient’s will of ending life: “Patients should have the right to refuse life-extending treatments if they choose” (#1, 3*). In addition, they do not express a preference regarding sentences that imply a greater expenditure in end-of-life care: “If a life-extending treatment for terminally ill patients is expensive, but is the only treatment available, it should still be provided” (#8, 0*); “We should spend proportionately more on patients when we feel those patients have not had their fair innings – in terms of the length of their life or the quality of that life” (#13, 0*); “Treating people at the end of life is not going to result in big health gains but the health system should be about looking after those patients in greatest need” (#27, 0*).
Unlike respondents with profile 2, people included in this profile strongly reject to extend life just to keep the patient alive, disagreeing with the statements which advocate this idea: “Life is sacred and if it is possible to preserve life, every effort should be made to do so” (#22, -3); “A year of life is of equal value for everyone” (#12, -3*); “Not giving access to life-extending medicine to a person with a terminal illness is the same as killing them” (#16, -2*); “To extend life in a way that is beneficial to the patient is morally the right thing to do” (#14, -2). On the other hand, respondents in this group present some similarities with group 1, since they consider that life extension is only worth and ethic if it results in actual health gains, not just stopping death from happening: “I wouldn’t want my life to be extended just for the sake of it – just keeping breathing is not life” (#23, 3); and provided quality of life will be good: “Life should only be extended if the patient’s quality of life during that time will be good” (#10, 2); “Real help and compassion should be about providing a death with dignity instead of more drugs to get a few more weeks or months out of a very sick body” (#11, 2).
Characteristics associated with the profiles
Respondents’ characteristics associated with the profiles are presented in Table 3.
Table 3
Respondents' characteristics associated with the profile
| | Profile | |
Variable | Category | Profile 1: Students prioritising patient’s will and quality of life | Profile 2: Students believing that life must be extended whatever the cost | Profile 3: Students maximising health benefits and economic aspects | P-value |
Year of studies | First to third year students n(%) | 9(24.32) | 15(40.54) | 13(35.14) | 0.258 |
Fourth to fifth year students n(%) | 7(18.42) | 16(42.11) | 15(39.47) |
Sixth year students n(%) | 9(19.57) | 11(23.91) | 26(56.52) |
Average grade* | 5-<7 n(%) | 5(15.63) | 13(40.63) | 14(43.75) | 0.444 |
7–8 n(%) | 14(25.00) | 19(33.93) | 23(41.07) |
> 8 n(%) | 4(16.00) | 6(24.00) | 15(60.00) |
Previous contact with terminally ill patients in clinical clerkship | none or scarce n(%) | 14(17.50) | 28(35.00) | 38(47.50) | 0.634 |
some or frequent n(%) | 7(25.00) | 10(35.71) | 11(39.29) |
Lives with family | No n(%) | 12(19.35) | 25(40.32) | 25(40.32) | 0.409 |
Yes n(%) | 13(22.03) | 17(28.81) | 29(49.15) |
Both parents with university studies | No n(%) | 12(18.46) | 20(30.77) | 33(50.77) | 0.342 |
Yes n(%) | 13(23.21) | 22(39.29) | 21(37.50) |
Religious beliefs | No n(%) | 22(27.50) | 22(27.50) | 36(45.00) | 0.012 |
Yes n(%) | 3(7.32) | 20(48.78) | 18(43.90) |
Influence of religious beliefs in ethical principles | Never/Scarce/No/Not applicable/ n(%) | 24(24.74) | 26(26.80) | 47(48.45) | 0.001 |
Yes/Sometimes/Always n(%) | 1(4.17) | 16(66.67) | 7(29.17) |
Influence of personal experience with terminal patient in EoL care opinion | Never/Not applicable n(%) | 12(17.91) | 20(29.85) | 35(52.24) | 0.064 |
Sometimes n(%) | 5(15.63) | 12(37.50) | 15(46.88) |
Always n(%) | 8(36.36) | 10(45.45) | 4(18.18) |
Gender | Male n(%) | 8(20.51) | 13(33.33) | 18(46.15) | 0.969 |
Female n(%) | 17(20.73) | 29(35.37) | 36(43.90) |
Age (mean(sd)) | | 22.42(3.74) | 21.77(2.15) | 21.91(1.67) | 0.565 |
*Grading in Spanish universities are 0–10. 5 points are required to pass. |
The only two variables significantly associated with the profiles were the respondents’ religious beliefs and the influence they considered these beliefs have on their ethical principles. Those students who profess religious beliefs are included in profile 2 in greater proportion (48.8% vs 7.3% in profile 1 and 43.9% in profile 3), while those who consider their beliefs do not influence their ethical principles are included in a greater proportion in profile 3 (48.5% vs 24.7% in profile 1 and 26.8% in profile 2).
It should be noted that profile 3 was the least numerous in students who believed that their previous personal experience with a close relationship with terminally ill patients conditioned their position (18.2%). On the contrary, this third profile was predominant in those who did not have this experience or believed that, despite having the experience, they were never influenced by it (52.2%). No differences associated to sex, age, year of studies, average grade, previous contact with terminally ill patients or living with their family were found.